About Scars

What is a scar?

Forming a scar is a normal part of the healing process. It is the body’s natural way of repairing and strengthening damaged skin.2 When an injury to the skin goes deeper than the top layer of skin (the epidermis) into the middle layer (the dermis) a scar may be formed as part of the healing process.3 Scars are formed as the body needs to repair the damaged skin quickly.4 Anything that can damage skin can lead to the formation of a scar such as:5

Infections, for example following chicken pox

Trauma or injuries, for example following an accidental cut, a fall, burns or surgery

Inflammation, for example due to acne

Stretch marks are another form of scar that appears after rapid growth of skin, as can occur during pregnancy.2

The more the skin is damaged and the longer it takes to heal, the greater the chance of a noticeable scar being formed.6 Also the more tension or pulling there is around the damaged skin the higher the chance of a scar forming. This is common if the damaged skin is on or near a joint that is always moving such as a knee or elbow.2,6

A scar is different to normal skin. It is made of different materials (mainly collagen) and has a different structure to normal skin. This makes the scar less flexible and weaker than the original skin.4,7 Other structures that are normally found in the skin such as sweat glands and hair follicles are not found in scar tissue. This is why scars look different to normal skin.4,7

When scars are first formed they can appear red, thick and raised. Even though scars are permanent, during the healing process (that can take up to 2 years to complete) the scar may gradually become smoother, softer and paler.2The appearance of a scar can be visually improved with silicone based treatments such as DermaScar®.1

What influences scar formation?

Age

Genetics

Location

Infection

Age

Age

Injury in teenagers and young adults normally results in worse scarring than the same injury in elderly people.8 Keloid scars, which are the result of an over production of collagen, tend to occur more readily in younger people aged under 30 years, and are most common during and after puberty.9,10

Genetics

Genetics

People with darker pigmented skin such as those of African, Asian or Hispanic descent are more prone to form abnormal scars, such as keloid scars.8–10

Location

Scar Location

Skin or wound tension (pulling or stretching) with movement can increase the risk of a scar forming. If the injured skin is over a joint or part of the body that moves a lot then extra care may be needed to try and prevent scar formation.9

Infection

Wound infection and complications

Wound infection, in particular after a burn injury, increases the chances of abnormal scars being formed.11Delayed healing (longer than 3 weeks) can increase the risk of raised keloid scars being formed.10

Problems with Scars

While scars are often considered as trivial by some people, some scars can cause additional medical issues.8 Unfortunately some scars are disfiguring and unattractive to look at and this can be very distressing, especially if you feel that you are being stared at. These feelings can lead to other issues such as being less socially active, loss of self-esteem, feeling anxious or even depressed.2,8 In addition to how some scars make you feel, scars can also cause unwanted physical issues. Some scars can be very tender, painful and itchy. These symptoms can be so severe that it causes other problems such as difficulty getting a good night’s sleep.8 As scars are less flexible than normal skin, some scars will limit the person’s ability to move and in severe cases can be disabling.8 If you feel that your scars are affecting your daily activities or you are feeling anxious or depressed, make sure you see your doctor to talk about your concerns.2

Common Types of Scars

Flat, pale

Atrophic

Hypertrophic

Keloid

Contracture

Stretch

Flat, pale

Flat, pale scars

These are the most common type of scar, occurring as a result of normal healing. At first these scars may be red, dark and raised, but over time (up to 2 years) they will tend to become paler and flatter.2

Atrophic

Atrophic (“ice-pick”) scars

These scars are sunken down into the skin, looking like a valley or pick-hole in the skin. It is like some of the inner layers of the skin are missing causing this sunken appearance.5 Atrophic scars are often caused by inflammation as can occur with acne or infections such as chicken pox4,5,12 Sometimes this type of scar is formed following an injury where there is a loss of tissue under the skin.4,5,12

Hypertrophic

Hypertrophic scars

Are usually red or purple and are raised above the surrounding skin. These scars are due to an over production of collagen and normally form along the site of the wound, for example following surgery. These scars sometimes fade and become flatter over time, but can remain discoloured and raised for a number of years.2,4

Keloid

Keloid scars

These are very elevated red or dark scars that form when the body produces too much collagen. They often spread larger than the area of the original injury and can continue to become larger even after the original wound is fully healed.2,4

Contracture

Contracture scars

These types of scars are caused by the skin shrinking and tightening during the repair process. Contracture scars often happen after a burn and end up pulling the skin in towards the site of the injury. This can make the skin look puckered around the wound.2,4

Stretch

Stretch marks

These scars appear after rapid growth of the skin, such as occurs during pregnancy.2 Here the scar is sunken a little into the skin. The most common locations for stretch marks are around the abdomen (or belly), breasts, upper arms, underarms, back, thighs, hips and buttocks.4

Wound healing

The epidermis (the top layer) which acts as the final barrier between the body and the outside world

The dermis (the layer under the epidermis) which provides the main structures in the skin including blood vessels, nerves, sweat glands and hair roots, and

The subcutaneous layer, the innermost layer that acts as a cushion and connects the skin to other organs in the body.

Structure of normal skin

Repairing damaged skin is a complex process that starts immediately following the injury.3 The exact process that will take place depends on the type and extent of the injury,14 however it generally involves three phases.3

During this phase the body’s immune system is working and this causes localised inflammation with the damaged area often becoming red, hot, swollen and painful.3,14 This inflammatory phase continues for the first 48 hours after the injury.3

Phase 2

The second phase of wound healing occurs between 2 and 10 days after the injury. During this phase rebuilding begins and new tissue is formed.3 New skin cells begin to grow to produce a scab that covers the wound. Under the scab, new tissue is also being formed including the formation of a new blood supply to the damaged area. Towards the end of this phase the base of the scar starts to form. This occurs when special types of cells, called fibroblasts, attach themselves to the edges of the wound and start producing collagen that will eventually close the wound by forming a scar.3 The scar that is forming at this stage of the healing process is typically very red.4

Phase 3

The final phase of healing, the remodelling phase, begins once the wound is closed. This is the longest stage in the healing process and can continue from 1 month to a year or even more depending on the size and nature of the injury.3 During the early stages of this phase more collagen is produced so that the wound is closed by the scar. As more collagen is laid down the scar becomes thicker and stiffer. The thickening of the scar decreases blood supply to the area and slowly the scar will start to fade or become paler.4,14 Over time the nature and structure of the collagen in the scar changes (or is remodelled) to strengthen the scar tissue. However, the scar tissue is not as strong as normal undamaged skin and so the area is more open to further damage in the future. As scars are less flexible than normal skin, this can limit the ability of the body to move if the scar is large or near a joint.4 With time, scars generally become smaller at the outer surface of the skin and the scar becomes flatter. However, sometimes a raised scar will persist due to the overproduction of collagen. This can result in a hypertrophic scar or a keloid scar.

Caring for Scars

It is not possible to prevent scars from forming,8 but there are some things that can be done to make your scar less visible and help the healing process. For example, when an injury first occurs, cleaning the dirt from the wound and applying an appropriate dressing can help the healing process.2 Try not to scratch and pick at scabs as this is part of the healing process and by removing the scab you are interrupting healing.2 Once the wound has healed, the early and regular use of DermaScar® can help change the appearance of a scar, making it lighter in colour, softer, more flexible and flatter. The use of silicone gel treatments such as DermaScar® may also help reduce pain and itchiness associated with scars and can help prevent the formation of abnormal scarring.1,15 To get the best results it is important to act early, once the wound has healed, but while the scar is still young and not fully developed.16

[6] Grahame, R. A method for measuring human skin elasticity in vivo with observations of age, sex and pregnancy, Clinical Research Division, Kennedy Institue or Rheumatology, West London Hospital 1969